ATI Finals As Derived From ATI Text For Nursing Fundamentals, Part II

Which of the following can be recommended to a patient suffering from constipation?

• Fresh fruits and whole wheat toast

• Noodles with beef tips

• Mashed potatoes with gravy

• Macaroni and cheese

A patient has been sitting on a chair for 3 hours. Which of the following could this patient be at risk for?

• Stasis of secretions

• Muscle atrophy

• Pressure ulcer

• Fecal impaction

A client experiences dyspnea and reports feeling tired after completing her morning care. Which of the following should the nurse include in the client's plan of care for the next day?  

• Plan several rest periods during morning care

• Do not offer any morning care

• Perform all of the client's care as quickly as possible

• Ask a family member to come in to give the client a bath.

After an enteral feeding is given, what is the purpose of flushing a tube?

• Provide sufficient fluid intake

• Dilute concentration of formula

• Clear the tubing to prevent clogging

• Ensure placement of tube is maintained

A nurse should know that pain is.........

• Most clients exaggerate their pain level

• Pain must have an identified source before using opioids

• Pain is whatever the client says

• Objective data are essential in assessing pain

A nurse is teaching a group of young adults who are about to go for a marathon. Which of the following should she teach?

• Increase fluid intake in dry climates

• Decrease fluid intake in high altitudes

• Include caffeine as a regular beverage

• Decrease fluid intake after training

A patient with chronic high blood pressure has been prescribed with an antihypertensive drug. Which of the following should the nurse teach to this patient with regards to over the counter (OTC) medications? 

• Continue taking OTC drugs with antihypertensive medication

• Consult physician before taking an OTC drug

• Stop taking antihypertensive drugs while taking OTC drugs

• Take only one half the recommended dose of OTC medications.

A nurse is assessing a client with pneumonia with a long history of osteoarthritis on her knees. Although she has a pain of 6 out of 10, her vitals indicate a normal range, and she does not show any muscle tension. Why? 

• The client must have had a larger dose of analgesics.

• What she has is a cultural expression of pain.

• As pain continues, the body is not able to sustain the level of sympathetic response, and the parasympathetic nervous system takes over. The client can still be in pain without a physiological manifestation.

• It is most probable that the patient is malingering.

While assessing a patent with a continuous enteral feeding, nurse noticed aspiration if the tube feeding. What should she do next?  

• Auscultate breath sounds

• Stop the feeding

• Obtain a chest x-ray

• Provide oxygen

A nurse is caring for a client who is dyspneic. What position should the client be in?

• Supine

• Dorsal Recumbent

• Fowler's

• Lateral

The belief that one's culture is superior to others is called 

• Ethnocentrism

• Socialization

• Repatterning

• Acculturation

Nitroglycerin (Nitrogard) tablets, often prescribed for patients with cardiovascular disorders, are given sublingually. What does this mean?

• Crushed and ingested with a small amount of food

• Held under the tongue until dissolved

• Taken by mouth with a small amount of water

• Placed between the cheek and gums

A client with an indwelling catheter expresses the need to void. Which of the following is appropriate?

• Check to see if the catheter is patent

• Reassure the client that it is not possible for her to urinate

• Recatheterize the client with a larger-gauge catheter

• Notify the provider

A nurse is assessing the pain level of a client admitted to the ER with severe abdominal pain. The nurse asks the client if he has nausea and vomiting. What is being assessed?

• Location of the pain

• Pain quality

• Associated symptoms

• Aggravating and relieving factors

Which of the following nursing interventions should be implemented to maintain a patent airway in a client on bed rest?

• Isometric exercises

• Suction every 8 hours

• Administer low dose of heparin as prescribed

• Teach the use of an incentive spirometer while awake

An 81-year old patient has been transferred from a long term care facility to an acute care setting. An indwelling urinary catheter was inserted just before her transfer. Which of the following may help prevent the development of nosocomial infection?

• Assess the patient's ability to void independently

• Place an absorbent pad under the patient to protect the bed in case of incontinence

• Frequently clean the patient's perineal area and properly care for her catheter

• Give the client a diet high in fiber to prevent constipation.

A patient claims that his pain medication is not working as it used to. The nurse should realize that the client is experiencing what?

• Placebo effect

• Tolerance

• Accumulation

• Dependence

 A nurse is setting up an injection of morphine (Duramorph) to a patient who complains of pain. Before this however, another client in another room called and requested for a bedpan.  This nurse then asked for a second nurse to give the injection so that she can help the client needing a bedpan. Which of the following actions should the second nurse take?  

• Give the injection prepared by the other nurse

• Offer to assist the client needing a bedpan

• Prepare another syringe and give the injection

• Tell the client needing a bedpan that she will have to wait for her own nurse.

What is the main function of a sequential compression device (SCD)?

• Promote venous return

• Prevent pressure ulcers

• Prevent muscular atrophy

• Increase joint mobility

An older adult has been taking a bath in the morning following a facility's routine. At home, however, she always takes a warm bath just before bedtime. Now she is having difficulty sleeping at night. Which of the following interventions should the nurse take first?   

• Rub her back for 15 minutes before bedtime

• Offer her warm milk and crackers at 2100

• Allow her to take a bath in the evening

• Ask her provider for a sleeping medication

The enteral access tube best suited for short-term use (less than 4 weeks)

• Nasogastric tube

• Gastrostomy tube

• Jejunostomy tube

• PEG tube

Which of the following interventions is expected when performing catherization on a female patient? Select all that apply: 

• Maintain surgical asepsis throughout the procedure

• Provide privacy

• Darken the room

• Ask the client not to talk during the procedure

• Position patient with knees bent and apart

Frequent pain assessment includes quantifying the intensity of pain. What is the best way to assess this? 

• Ask what precipitates the pain

• Question client about pain location

• Offer client a pain scale to measure his pain

• Use open ended questions to identify the sensation

Which of the following is the body's preferred energy source? 

• Fat

• Protein

• Vitamins

• Carbohydrates

A nurse is caring for a client who weighs 80 kg (176 lbs) and is 1.6 m ( 5 ft 3 in) tall. Calculate her body mass index (BMI) and determine whether or not client is obese on her BMI  

An 85-year old diabetic patient must now use a wheelchair after a stroke 2 years ago that affected her right side. She feels no pain on this side. Although she has a good appetite, she needs help with eating. Which of the following factors could cause this patient to have pressure ulcers?

• Dehyrdation

• Limited mobility

• Nutritional impairment

• Incontinence

Which of the following is a STAGE III DECUBITUS?

• Reddened skin and does not blanch with pressure

• Ulcer is an abrasion or a blister

• Bone is exposed at the center of the ulcer

• Ulcer extends past the subcutaneous tissue to the muscle

A nurse is taking care of a patient with back pains. This patient tells the nurse that a friend recommended him to see a chiropractor. She asks the nurse what a chiropractor does to relieve back pain. Which of the following responses by the nurse would be correct?

• Chiropractors insert needles or put pressure along meridians in the back

• Chiropractors use their hands to balance the energy fields in the back

• Chiropractor use herbal remedies to treat back pain

• Chiropractors use their hands to manipulate the spine to treat back pain

A client is observed crying as he reads from his devotional book. What intervention is appropriate? 

• Contact the hospital's spiritual services

• Ask him what is making him cry

• Provide quiet times for these moments

• Turn on the television for a distraction

Which of the following positions promotes a patient's normal elimination?

• Left lateral Sim's

• Supine

• Right side-lying

• Sitting

A home-bound patient needs to perform a fecal occult blood testing at home. Which of the following should be included when explaining the procedure to the patient? 

• Eat more protein before testing

• One stool specimen is enough for the test

• The specimen cannot be contaminated with urine

• A red color change indicates a positive test

Which of the following is a sign of impending death?

• Elevated blood pressure

• Warm extremities

• Tense muscles

• Labored breathing

Which of the following prevents medication error?

• Taking all medications out of the unit-dose wrappers before entering the bedside

• Giving up the prescribed medication and then looking up the dosage range

• Relying on another nurse to clarify a medication prescription

• Checking with the physician when a single dose indicates an administration of multiple tablets

A nurse is assigned to a patient with a high risk for aspiration. Which of the following is an appropriate intervention?

• Give the patient thin liquids

• Instruct the client to tuck her chin when swallowing

• Have the client use a straw

• Encourage the client to lie down and rest after meals

If not supervised, school-age children tend to have dietary deficiencies in which of the following?

• Carbohydrates

• Fats

• Minerals

• Vitamins

When performing a 24-hour urine specimen test, which of the following interventions is correct? 

• Keep all voidings in a container at room temperature for 24 hours.

• Discard the first voiding

• Ask patient to urinate into the toilet, stop midstream, and finish urinating into the specimen container.

• Ask patient to urinate and pour the urine into a specimen container

Before initiating an enteral feeding, what is the highest priority assessment that the nurse must do?

• Is the tube correctly placed?

• Is the client alert and oriented?

• How long has the feeding container been open?

• Does the client have diarrhea?

When implementing medication therapy, the nurse's responsibilities include which of the following? Select all that apply:

• Observe patient for drug side effects

• Monitor for therapeutic effects

• Prescribing an appropriate dose

• Maintain a current knowledge base

• Changing the dose if side effects take place

After a PO medication has been absorbed, most of the medication is inactivated as the blood initially passes through the liver, producing an insignificant therapeutic effect. What do you call this? 

• Tolerance

• Antagonism

• Synergism

• First pass effect

Which of the following are true about pain?

• All cultures have the same attitude regarding pain

• Pain can cause anger and guilt

• In may be tough to assess pain properly in a client who is cognitively impaired.

• A client who is sleeping could not be experiencing pain

• It is best to wait until pain worsens before administering analgesics

For a CVA patient who is wheel chair bound, which of the following can prevent skin breakdown?

• Massage bony prominences frequently

• Keep patient on high fowler's position while in bed

• Have the client sit on a donut shaped cushion

• Encourage repositioning every 15 minutes while the client is on a wheelchair.

Upon looking at the MAR, a nurse observes that one of her clients is taking four new mediations. Which of the following should be a concern?

• The client is lactose intolerant

• Two of the medications cause drowsiness

• There are no generic forms available

• The client has difficulty swallowing four pills at one one time

An entry in a patient chart indicates wound drainage is "sanguineous". What does this mean? 

• Foul-smelling

• Green-tinged or yellow

• Watery in appearance

• Bright red

  A male patient was admitted for abdominal surgery. Client's initial vital signs are temperature at 37 C (98.6 F), pulse 98 / min, respirations 20 / min and blood pressure at 148 / 88 mm Hg. The client states, :I am really worried. This is the first surgery I ever had." Which of the following is an appropriate use of a complementary alternative intervention?

• Call provider and get permission to use relaxation techniques with the patient.

• Offer information and ask the client if he is interested in trying a relaxation technique

• Provide client with reassurance and information about the procedure

• Give client a therapeutic back massage and tell him to try to relax

Which of the following formula contains a complete nutrition?

• Polymeric

• Modular

• Elemental

• Specialty

Which of the following can alter the results of blood glucose testing?

• Amoxicillin (Amoxil)

• Dexamethasone (Decadron)

• Morphine (Duramorph)

• Acetaminophen (Tylenol)

Which of the following should be a part of a care plan designed for a hypernatremic patient?

• Administer a loop diuretic

• Increase sodium intake

• Restrict oral intake of water

• Infuse hypotonic IV fluids

A 70-year old female has had a bowel obstruction surgery six days ago. During the past day, she has complained of nausea, and she threw up small amounts of clear liquid in the last 7 hours. Her vital signs are stable. Currently, her incision is well approximated without redness, tenderness or swelling. Which of the following could indicate the possibility of a wound infection?  

• Increased pain

• Decreased pulse rate

• Decrease WBC count

• Increased thirst